Physician Registration Form

Join Our Physician Network & Market Your Practice

ONLINE PHYSICIAN FINDER REGISTRATION FORM
for Urologists using Narrow Band Imaging (NBI®) or Plasma Resection

Thank you for your interest. The online Physician Finder will allow patients to find a Urologist in their area using NBI, plasma (bipolar) resection or both technologies in their practice. Join our network by registering your practice in our Find a Physician tool and help patients to find an NBI and/or Plasma Therapy doctor close to home.

All fields marked with a '*' are required.

First Name *

Last Name *

Email

Facility/Organization *

Address Line 1 *

Address Line 2

City *

State *

Zip *

(Please, only numerical values.)

Telephone

Olympus Representative *

Website of Your Facility

Technologies in Use *

Consent *

For valuable consideration received, I hereby grant Olympus America Inc., and/or its affiliates, representatives, and those acting with its authority or permission (collectively, “Olympus”) the right and permission to use, publish, depict, and display, my name, image (if supplied), the name of my employer, and field of expertise, on Olympus’ physician finder website. I hereby warrant that I have the right to contract in my own name, and if I am employed by an institution, that I have the authority to execute this Consent and Authorization on behalf of my institution.

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